Duties: • Responsible for conducting timely reviews of all requests for services required to meet medical necessity criteria to include reviewing pre-certification for outpatient and inpatient services. • Applying criteria to inpatient admissions and performing concurrent review functions, identifying discharge planning needs and referral of members to case management.
Principal Accountabilities: • Evaluates clinical information submitted by providers against plan review criteria and benefit guidelines. • Utilizes clinical information to determine if criteria for medical necessity and benefit guidelines are met. • Utilizes professional judgment to determine if additional information is required, then follows through to obtain additional information prior to making a decision. • Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet intermural medical necessity criteria to Medical Director for review and final determination. • Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for members. • Acts as a liaison to assure services are provided in the least restrictive, most cost effective and clinically appropriate setting. • Works with the Utilization Management Manager, the Medical Director and providers to ensure that complete medical information is available to allow utilization management decisions to be made within The Plan's standards for decision making. • Identifies potential members who may benefit from case management services and facilitates referral to the program. • Identifies and resolves any problems that could interfere with provider's continuity and coordination of care of members and refers unresolved problems to Manager. • Creates and maintains monthly reports on inpatient activities. • Performs other related duties and projects as assigned. • Adheres to ACFC policies and procedures. • Supports and carries out our Mission & Values. Skills: • Two years of experience in managed care quality assurance or utilization review. • RN must have two years of experience in an acute care hospital.